CLIENT INTAKE FORM CLIENT INTAKE FORM CLIENT INTAKE FORM Welcome to SIMPLY DAWN! We are excited to help you achieve your beauty, skincare, and wellness goals! The information provided by you on this form is important and will help document allergies, sensitivities, or contraindications that may be present prior to receiving any treatment or beginning any program (whether spa or clinical). Your answers will affect the types of services, active product ingredients, and equipment modalities that can be safely used to provide services for you. Please be sure that the information you provide is accurate and thorough. We want your experience to be exceptional, and we want to ensure that your treatments are safe and effective. Thank you for helping us set you up for success! Basic Information Name * Name First First Last Last Birth Gender * Female Male Birthday (M/D/Y) * Email * Mobile Phone * Address Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Occupation On a scale of 1-10, please rate your stress level: 1 2 3 4 5 6 7 8 9 10 How did you hear about us? FriendFamily MemberWebsiteInstagramFacebookOther How did you hear about us? If other, please list: If you were referred, please list the name of the person who referred you so we may thank them. Medical History & Lifestyle CURRENT MEDICATIONS / USED FOR: KNOWN ALLERGIES / TYPE OF REACTION: Are you currently pregnant or nursing? Yes No Have you ever taken isotretinoin (Accutane)? Yes No If yes, how long ago? Are you currently using any prescription keratolytics? (tretinoin, Atralin, Retin-A, Renova, Differin, Tazorac, Avage, EpiDuo, Ziana, etc.) Yes No If yes, what type and how often? Do you have Herpes simplex or do you get frequent cold sores? Yes No If yes, do you have antiviral medication? (Valtrex, Zovirax, Famvir, etc.) Are you currently taking antibiotics or photo-sensitizing medications? Yes No If yes, please list: Do you have any permanent cosmetics? Yes No If yes, what areas? Do you tan your skin, either by sunlight or tanning bed? Yes No If yes, how & how often? Do you have any present illnesses? Yes No If yes, please explain: Have you been treated for cancer? Yes No If yes, what type & how long ago? Do you have any thyroid abnormalities or conditions? Yes No If yes, please explain: Do you have problems healing from a cut or burn? Yes No Have you been treated with Botox or any dermal filler injectables? Yes No If yes, how long ago & what area/s? Do you have a pacemaker? Yes No Do you have any electrical or metal implants of any kind? Yes No If yes, what type & where? Are you currently using any AHA/BHA based products? Yes No If yes, what? Are you allergic to lidocaine or any other type of topical anesthesia? Yes No If yes, what type & how do you react? Do you currently receive waxing services? Yes No If yes, what areas & when was your last treatment? Do you participate in vigorous aerobic activity or sports? Yes No If yes, what type & how often? Do you smoke or use tobacco? Yes No If yes, how often? Do you drink alcohol? Yes No If yes, how often? Have you had a chemical peel or a procedure with a medical device? Yes No If yes, what & when was last? Do you have any type of auto-immune disorder? Yes No If yes, what type? Do you currently have an active bacterial infection? Yes No If yes, what type? Do you currently have an active viral infection? Yes No If yes, what type? PLEASE MARK ALL THAT APPLY: Epilepsy Heart condition History of seizures Diabetes Regular doses of aspirin Blood thinning medication Psoriasis Auto-immune disease Hairy moles Bleeding issues Allergy to latex Allergy to aspirin Use of self-tanning products History of keloid scarring HIV/AIDS Warts/HPV Hirsutism (hair loss) Polycystic Ovarian Syndrome (PCOS) History of histamine or rashy reactions Skin Typing WHAT ARE THE TOP THREE CHANGES YOU WOULD LIKE TO SEE IN YOUR SKIN? WHAT ARE YOUR MAIN AREAS OF CONCERN? WHAT PRODUCTS ARE YOU CURRENTLY USING ON YOUR SKIN IN THE MORNING? WHAT PRODUCTS ARE YOU CURRENTLY USING ON YOUR SKIN IN THE EVENING? PLEASE MARK ALL THAT APPLY: Normal Blackheads (comedones) Eczema Fine lines Dry Whiteheads (milia) Freckled Wrinkled Combination/T-zone Cysts Sun-damaged Patchy dryness Oily Breakouts Melasma Sallow Thick Acne scarring Hyperpigmentation Psoriasis Thin Large pores "Perfume staining" on neck Dehydrated (lacking moisture) Saggy Small pores Hypopigmentation Asphyxiated Firm Florid/flushed Uneven/blotchy Telangiectasias (broken capillaries) Acne (moderate to severe) Rosacea Mature Skin Type Assessment WHAT COLOR ARE YOUR EYES? (0) Pale blue, gray, green (1) Blue, gray, green (2) Blue (3) Dark brown (4) Brown black WHAT IS YOUR NATURAL HAIR COLOR? (0) Sandy red (1) Blonde (2) Dark blonde, chestnut brown (3) Dark brown (4) Black WHAT IS THE COLOR OF YOUR SKIN IN NON-EXPOSED AREAS? (0) Reddish, pinkish (1) Very pale (2) Pale with beige tint (3) Light brown (4) Dark brown DO YOU HAVE FRECKLES IN NON-EXPOSED AREAS? (0) Many (1) Several (2) Few (3) Incidental (4) None WHAT HAPPENS WHEN YOU STAY IN THE SUN TOO LONG? (0) Painful blistering, redness, peeling (1) Sunburn, followed by peeling (2) Burn, sometimes followed by peeling (3) Rare burns (4) Never burn TO WHAT DEGREE DO YOU TURN BROWN? (0) Hardly at all, many freckles (1) Pale tan, more freckles (2) Reasonable tan (3) Tan very easily (4) Turn dark brown DO YOU TURN BROWN WITHIN SEVERAL HOURS AFTER SUN EXPOSURE? (0) Never (1) Seldom (2) Sometimes (3) Often (4) Always HOW DOES YOUR FACE REACT TO THE SUN? (0) Very sensitive (1) Sensitive (2) Normal (3) Resistant (4) Very resistant WHEN DID YOU LAST EXPOSE YOUR BODY TO THE SUN, A TANNING BED, OR OTHER FORM OF UV LIGHT? (0) More than 3 months ago (1) 2-3 months ago (2) 1-2 months ago (3) Less than one month ago (4) Less than two weeks ago HOW OFTEN DOES YOUR FACE/NECK/DÉCOLLETÉ RECEIVE UV EXPOSURE (sun, tanning bed, etc.)? (0) Never (1) Hardly ever (2) Sometimes (includes incidental sun exposure) (3) Often (4) Always PLEASE TOTAL THE POINTS FROM YOUR ANSWERS ABOVE: (1) 0-7 points (2) 8-16 points (3) 17-25 points (4) 25-30 points (5) 30+ points PLEASE CHECK THE BOX THAT DESCRIBES YOUR SKIN AFTER A MODERATE PERIOD OF SUN EXPOSURE WITHOUT SUNSCREEN: Always burns, never tans Usually burns, very minimal tan Mildly burns, tans relatively well Rarely burns, tans well Very rarely burns, tans easily Doesn't burn, tans very darkly WHAT IS YOUR ANCESTRAL BACKGROUND? PLEASE MARK ALL THAT APPLY AND LIST ANY ADDITIONAL ETHNICITIES ON THE LINE BELOW: Swedish Danish Irish English Welsh Asian Italian Greek Hispanic Middle Eastern Native American Southeast Asian African American ADDITIONAL ETHNICITIES NOT LISTED ABOVE: By signing this form, I am acknowledging that I have completed this information to the best of my knowledge, and I have been candid in disclosing the information requested. I understand that this information will be used to determine specific skin sensitivities, allergies, and contraindications that may be present prior to receiving treatment. I also understand that this information will be used to determine which products, modalities, and ingredients may safely be used on my skin during treatment. I acknowledge that my practitioner may use before and after pictures for business purposes, and that I may request to have my identity masked. I give my permission and consent to receive treatment. Signature signature keyboard Clear Date Submit If you are human, leave this field blank.
